I existing clinical trials or attempt to highlight the exciting new developments emerging from the laboratories of our basic scientists and today's clinical trials. Likewise I do not decry the still daunting problems which face those concerned with the common, therapy-resistant cancers which kill so many of our citizens. Instead I intend to describe the environment, as I see it, in which today's clinical trials are proposed and conducted and the impact which this environment has upon progress in clinical medicine as reflected by a healthy clinical trials program. If these environmental issues are not reasonably resolved, the prognosis for seizing and applying our present advances is dismal. In short, the problem is rapidly becoming not one of a paucity of good ideas but rather of a morass of obstacles. I will present only a brief discussion of five of the most important problem areas, and I will not attempt to review all of the possible issues. As I see it, the five most important are: (1) how to integrate clinical trials and their funding into a health care delivery system which appears to be in chaos; (2) how to sharpen the science of clinical trials; (3) how to increase accessions to trials optimally; (4) how to address the legitimate, ethical concerns which are emerging as a result of current trials; and (5) how to arbitrate successfully the territorial concerns of the leaders in clinical oncology with those of community oncologists and members of the National Cancer Institute (NCI) staff.
Before addressing each of these issues, however, there is an overriding general environmental condition which faces us all, i.e., the antiintellectual nature of our times. About this there is much public and professional ambivalence. Science and its conduct are poorly understood, and its products are often frightening. Society decries our falling behind in mathematics and science, but the public believes that the same effort which so successfully probes the depths of the nucleus also brings the threat of nuclear